top of page

Mental Health Intake Form

General Info

Please provide us with basic information about yourself.

Date of Birth
Month
Day
Year
Gender
Marital Status:
Ethnicity
Multi-line address
Is this a textable number?
Preferred method of contact

Mental Health Info

The information you provide will help Stored Goodness better understand your needs and connect you with the most appropriate mental health resources. All details shared will be used solely for referral purposes to ensure you receive support that aligns with your preferences and situation. We value your privacy and are committed to handling your information confidentially.

Are you currently in crisis or immediate danger of yourself or someone else?

If this is an emergency, please dial 911 or contact the Suicide & Crisis Lifeline at 988 (available 24/7).

Your safety is the top priority. Help is always available.

Are you currently experiencing or have experience any of the following within the last 7 days? (Check all that apply)
Have you been diagnosed by a healthcare professional with any of the following mental health conditions? (Check all that apply)
What kind of support are you looking for? (Check all that apply)

By signing, you confirm that the information is true and accurate. You authorize Stored Goodness to share your information only with referral sources as needed to support your care. You understand that all information is kept confidential.

Date and time
Month
Day
Year
Time
HoursMinutes
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Stored Goodness Info

OFFICE USE ONLY

bottom of page